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Home My WebLink About0050 REDWOOD LANE ,�'o �Epulaod ,L.�N� - - f �F11IE r Town of Barnstable . *Permit# r Expires 6 months front issue date BAMSTABLB, : Regulatory Services Fee 9 "39. ,0$ Thomas F.Geller,Director Building Division Tom Perry, Building Commissioner IEE RR 'T 200 Main Street, Hyannis,MA 02601 MAY 1 0 2005 Office: 508-862-4038 Fax: 508-790-6230 1 OWN OF BARNSTABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number S9 0 e , Property Address O I(n�� - J ti V*tiA..- Residential Value of Work ?0-00 Minimum fee of$2 .00 for work under$6000.00 Owner's Name&Address S eK 0 0 ? Contractor's Name '�' + .r2� Lj y 1. Telephone Number S's ff 4T% �d� Home Improvement Contractor License#(if applicable) 14 3 3 S Construction Supervisor's License if applicable) G 0 g 5 2.13 P ( PP ) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name t 4f T-4b 'r} Workman's Comp.Policy#_ b 7 03304 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to�'r(ft�'i C� .da a 11 ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side 5tReplacement.Windowt U-Value • �`� (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of.Permission.' ';ll Home Improvement Contractors License is required. Signature Q:Fonns:expmtrg Revise063004 GT/e-Pom.,k��w `ate 4 B;O'ARD Q:F BUILOWS REGULATIONS License CONI STRUCTI®N S,IiPERVISOR Number O'89213 965 I KA 4 :: 07 Tr.no: 89273 RI;CHARD M CA *? / c, J 20`5 BLACKTH ,.ORN s�Y ,e , b29+8 ,r l yxw i 3 " M'AR�ST�®,NS MILLS Commissioner .��lng Board of$al ns and Standards MO;ME IMP'; .V'EMENT CONT 3 RACTOR ttggistratdnp ,_.. 58 r: 2 6 —=` Miry Corporation E ENTER CAPEWID " fv RICHARD CAPEN 205 BLACKH'ORN RD MARSTON MILLS,MA 02648 Administrator i The Commonwealth of Massachusetts - -� Department of Industrial Accidents Office of Investigations 600 Washington Street, Th Floor _- Boston,Mass. 02111 t �Jf I AlJ 1 7711\I IL_FLW a_1_1o_k rs�Com hnuaAfdMildinMumMinlictrical Contractors 4� name: address: city state: zip: phone# work site location(full address): - ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition ,f,--.'W7,F' E':'{�a''.�.•,ri-;.``..::,.�" �..x g��..,Nf c�-..�-.re- .;_t... .'y '.ls�a,.� I am an employer providing workers'compensation for my employees working on this job. company name* 1 address �• - b ct ��1/i �,`,"L-.._... ...........dl/V,E}`....0'�-l.3 L shone#: �O� �'2� .•T/ Insurance co. `� ^ oli Oc 1-6 ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: co an._name•. address: city nhone#• insurance co. ID011SX# comD2nv name: address: city phone#• insurance co. of M # Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties.of aline up to S1,500.00 and/or one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. r I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Print name Phone# .1�� 12,a mill i official use only do not write in this area to be completed by city or town official city or town: permitilicense# ❑Building Department CILicensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (mv'ised Sept 2003) . r Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied,oral or written. An employer is defined as an individual,partnership,association,corporation or other legal.entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of publicwork until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned.to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number whichwill be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements'have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,. please do not hesitate to give us a call. f The Department's address,telephone and fax number: , The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)7274900 ext. 406 . -01 09:03 USRLXL01 781-676-7510 >> 1-208-330-1380 P 3/3 FROM ; FAX NO. - Dec. 09 2OW 10:40PM P2 Town of Barnstable Regulatory Services Has Thomas P.Cedar,Dtredor '`'P Bujuding Division Tom Perry, "ding Commdartouer 200 M8 a Stmet, Hmmit,MA 02601 . wvvw.town.barnstablame.us Oflice: 508.862-4038 Fax: 508-790-6230 , Property Owner Must Complete and Sign This Section If Using&Builder L,-r— 1 � ,as Owner of the subject property hereby authorize to act on aw behalf, in ail Morten rela&n to-work authorized byWs buR&S permit application for. dress of job) Sig�aAM of owner ate Print Name